The Successful
Chinese Herbalist
Bob Flaws and Honora Lee Wolfe
2005
Blue Poppy Press
Published by:
BLUE POPPY PRESS
A Division of Blue Poppy Enterprises, Inc.
5441 Western Ave., Suite 2
BOULDER, CO 80301
Fir...
iii
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
CHAPTER 1. The Importance of P...
iv
Contents The Successful Chinese Herbalist
CHAPTER 12. How to Work with Patients Who Are Taking
Western Medication . . ....
v
Preface
Several years ago we published a book titled How to Write a
TCM Herbal Formula. This little volume was, for a ti...
Preface The Successful Chinese Herbalist
vi
This book is not a materia medica or a formulary text.
However, while limited ...
patient in the practice of Chinese herbal medicine. This
includes both diagnostic and prescriptive processes.
Advanced stu...
to their herbal medicine library. As always, we welcome your
suggestions on how we might improve our efforts when the
time...
The origins of Chinese herbal medicine
Standard professional Chinese medicine, or what is often
called Traditional Chinese...
According to Chinese texts, the defining methodology of
standard professional Chinese medicine as a specific style of
Chin...
understanding somewhere in this process. Thus, we present as
clear an explanation of the process of diagnosis and treatmen...
Most systems of medicine, including other styles of non-TCM
Chinese medicine and modern Western medicine, primarily
base t...
Standard professional Chinese medicine also begins with a
disease diagnosis. In contemporary professional Chinese med-
ici...
diseases will receive the same treatment if their patterns are the
same. This is the first fundamental thing to remember a...
Making a pattern discrimination
In standard professional Chinese medicine, only arriving at a
correct pattern discriminati...
in liver depression qi stagnation (gan yu qi zhi), the signs and
symptoms may include chest oppression, frequent sighing,
...
New practitioners are often confused as to which set of pat-
terns to use in their discrimination of a particular patient....
may find that a size six in one brand is the same as a size seven
in another. Within a single brand, a size six may be rig...
Such side effects contradict Chinese medicine’s holistic view of
the body as a totally integrated organism.
In addition an...
as a young practitioner. First, because most of us must learn
this system in translation, it’s easy for us to miss the ass...
sections on disease causes and disease mechanisms. This infor-
mation is what allows a practitioner to have an in-depth
un...
us to think flexibly and intelligently within the Chinese para-
digm of patterns.
However, in order to do this, a practiti...
Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1
15
Statement #1. The breast is circulated by s...
That being said, the other single most important thing that
we can say about making a Chinese medical pattern dis-
crimina...
Reframing your patients’ experience
In trying to unravel such a tangled skein of signs and symp-
toms, it is once again ve...
to reconnect with these physical feelings in order to match
up their complaints with Chinese, somaticized, pattern-dif-
fe...
once the exam for that class is passed. The good news is that
this information is still available and we can go back and l...
because it might make the problem easier to solve! Similarly,
as mentioned above, we must be able to account for every
sig...
Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1
21
Hallelujah Symptoms
While typically no one ...
inaccurate a certain percentage of the time. Intuition and gut
feelings may or may not help us, but a thorough knowledge o...
apart and then analyzed both separately and together to find
their clinical meaning.
Very commonly in the West, our patien...
more limited clinical component. Upon graduation, the most
common practice scenario in the West is a private, single pract...
what needs to be done in order to rectify the imbalance
implied by the name of the pattern. As such, they help to
lead us ...
four syllable groups. For instance, if a patient suffers from
spleen-kidney yang vacuity, the treatment principles might b...
In Chapter 1, we’ve reviewed the basics of analyzing your
patients according to the process of Chinese medical diagno-
sis...
ing to the logic and methodology of Chinese medicine, that I
should chose a formula from the qi-rectifying category of for...
potentially hundreds of formulas to a much smaller, more man-
ageable group. This is especially so if I stick with a reper...
vulnerable to disease transmission. Thus, if the liver qi has led
to spleen vacuity weakness complicated by blood vacuity ...
depressed to the point of transforming into heat, then one
must also add the principles: clear heat and resolve depres-
si...
To review this process, it was the statement of the principle to
rectify the qi that leads to the qi-rectifying category o...
Writing a Formula That Works for Each Patient Chapter 2
33
Western disease diagnosis: GERD
Chinese disease diagnosis: Stom...
We know that this formula does address and embody each of
these therapeutic principles by recognizing and understand-
ing ...
of not being adequately familiar with the traditional cate-
gories of formulas and the most important formulas within
each...
particular patient’s disease diagnosis, addresses their signs and
symptoms, and especially addresses their major complaint...
herbs are powerfully good in
the right situation, then it is
axiomatic that they can also be
powerfully bad in the wrong
s...
functions besides urination. If a patient is diagnosed as being
kidney yin vacuous but they do not have any irregularity i...
For instance, Huang Qi (Radix Astragali Membranacei) and
Dang Shen (Radix Codonopsitis Pilosulae) may be added to
Xiao Yao...
es it to overflow beyond measure. In this case, we may use
Dan Zhi Xiao Yao San as the guiding formula. But, based on
the ...
blood. Since the blood is the mother of the qi, the addition of
Dang Gui helps support the engenderment of qi. This ingred...
the issue of dose is one which requires discussion. If we look
at the dosages listed for a standard Chinese formula such a...
ers tend to prescribe highly modified and fairly complex for-
mulas at much higher doses per individual ingredient.
The di...
at higher than the usual doses. For instance, Pu Gong Ying
(Herba Taraxaci Mongolici Cum Radice) and Bai Jiang Cao
(Herba ...
gatherings, functions, indications, combinations, contraindica-
tions, and usual dosage ranges. We need to become so acqua...
advice on the modification and adjustment of dosages of for-
mulas based on the season and weather. For instance, some
her...
adult’s. We can also administer Chinese herbal decoctions to
infants and small children by the dropper. Most American
chil...
liquid after the liquid has been strained and the dregs removed.
Certain resinous powders, on the other hand, such as Hu P...
A somewhat similar method of stretching a single bao or
packet of medicinals is to decoct it twice and then pour
together ...
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
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[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
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[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
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[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist
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[Bob flaws, honora_lee_wolfe]_the_successful chinese herbalist

  1. 1. The Successful Chinese Herbalist Bob Flaws and Honora Lee Wolfe 2005 Blue Poppy Press
  2. 2. Published by: BLUE POPPY PRESS A Division of Blue Poppy Enterprises, Inc. 5441 Western Ave., Suite 2 BOULDER, CO 80301 First Edition, May 2005 ISBN 978-1-891845-29-2 LCCN #2005923635 COPYRIGHT © BLUE POPPY PRESS, 2005. All Rights Reserved. All rights reser ved. No part of this book may be reproduced, stored in a retrieval sys- tem, transcribed in any form or by any means, electronic, mechanical, photocopy, recording, or any other means, or translated into any language without the prior writ- ten permission of the publisher. DISCLAIMER: The information in this book is given in good faith. However, the author and the publishers cannot be held responsible for any error or omission. The publishers will not accept liabilities for any injuries or damages caused to the reader that may result from the reader’s acting upon or using the content contained in this book. The publishers make this information available to English language readers for research and scholarly purposes only. The publishers do not advocate nor endorse self-medication by laypersons. Chinese medicine is a professional medicine. Laypersons interested in availing themselves of the treatments described in this book should seek out a qualified professional practitioner of Chinese medicine. 10 9 8 7 6 5 4 3 2 1 Printed at Central Plains Book Manufacturing, Winfield, Kansas on acid-free paper and soy inks Text and cover design by Eric J. Brearton
  3. 3. iii PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V CHAPTER 1. The Importance of Pattern Discrimination in Crafting the Best Formula . . . . . . . . . . . . . . . 1 CHAPTER 2. Writing a Formula That Works for Each Patient . . . . . . . . . . . . . . . . . . . . . . . . . 27 CHAPTER 3. Forms of Chinese Herbal Medicines & Their Appropriate Use . . . . . . . . . . . . . . . . . . . . . . . . 63 CHAPTER 4. Potency Issues with Chinese Herbal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 CHAPTER 5. The Issue of Dose in Ready-made Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 CHAPTER 6. The Phenomenon of Habituation in Long-term Herbal Treatment . . . . . . . . . . . . . . . . . . . . . . . 87 CHAPTER 7. Possible Problems with Ready-made Medicines . . . . . . . . . . . . . . . . . . . . . . . . 93 CHAPTER 8. The Three Important Types of Potential Medicinal Toxicity . . . . . . . . . . . . . . . . . . . . . . 99 CHAPTER 9. Using Chinese Herbs During Pregnancy and Lactation . . . . . . . . . . . . . . . . . . . . . . . . 107 CHAPTER 10. My Favorite Formulas . . . . . . . . . . . . . . . 113 CHAPTER 11. How to Set Up & Run an Effective Chinese Herbal Pharmacy . . . . . . . . . . . . . . . . . . . . 141 Table of Contents
  4. 4. iv Contents The Successful Chinese Herbalist CHAPTER 12. How to Work with Patients Who Are Taking Western Medication . . . . . . . . . . . . . . . . . . 157 APPENDIX I: What’s Wrong with the Term “Patent Medicines?” . . . . . . . . . . . . . . . . . . . . . . . . 163 APPENDIX II: List of the Most Common Treatment Principles . . . . . . . . . . . . . . . . . . . . . . . . . . 169 APPENDIX III: Patient Herb Instruction Form . . . . . . . . . . . 177 APPENDIX IV: Problem Based Learning Exercise Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 APPENDIX V: A Representative List of Pesticides and Heavy Metals Tested by Western Companies Producing Ready-made Herbal Medicines . . . . . . . . . . . . . . . . . . . . . . . 205
  5. 5. v Preface Several years ago we published a book titled How to Write a TCM Herbal Formula. This little volume was, for a time, popular with schools and developed a small but loyal following. However, because the information it presented was limited to the administration of Chinese herbal medicine in decoction, and because it was really only an extra-long essay, at some point it needed to either be revised or to go out of print. Since its sales had never been huge, we allowed the book a quiet demise and transplanted the most important information it contained into other texts. In some senses, this new book is a direct lineal descendant of that first modest, but useful essay, now expanded to include a much broader range of subjects. There is so much to learn about the practice of any medicine. Some of the more practical elements of day-to-day practice and solutions to some of the more thorny problems that are inevitable can only be learned with time. Still, it is the job of any good teacher to shorten the journey of his or her students by sharing what they have learned by traversing a longer route. Thus, we have, with the publication of this new book, tried to address a variety of issues that are, for a variety of reasons, not always able to be taught in the context of the school clinic. We have written about our experience both as practitioners and as business people because we feel that the owning and operating of a dispensary is an integral part of the practice of Chinese herbal medicine in the U.S. and other countries where these medicines are not sold in standard pharmacies.
  6. 6. Preface The Successful Chinese Herbalist vi This book is not a materia medica or a formulary text. However, while limited to the practice of Chinese herbal medi- cine, the scope of the book is fairly broad. It includes discus- sions about everything we could think of that can and will make a positive difference in any practitioner’s level of success. Notably, the information about how to determine dosages using any and all types of Chinese medicines has not previous- ly appeared in the English language literature in this depth. Another chapter discusses the phenomenon of habituation, which is well known in the world of Western medicine but is rarely if ever discussed in Chinese herbal medicine texts. There is also a small but, we believe, useful chapter about working with patients who are taking Western drugs. Although the information presented here is by no means meant to be definitive and while we are working on a lengthy book on this same subject to be released in 2006, this chapter gives any practitioner a methodology to help them determine the impact of any Western drug on their patient’s health and how their treatments, herbal or other- wise, might improve such patient’s situation. Another important feature of this book from our point of view and one that we plan to include in most of our future publications is the problem-based learning exercises. These include case studies and questions at the end of most chap- ters. There is an answer key for these questions at the end of the book. While it may seem that this feature is mostly added for the sake of students, we have done our best to make the information and questions equally relevant for practitioners. We feel we must say something here about the first chapter of the book, which is a lengthy exposition on pattern dis- crimination and the processes one uses with each and every
  7. 7. patient in the practice of Chinese herbal medicine. This includes both diagnostic and prescriptive processes. Advanced students and some practitioners may feel this information is unnecessarily emphasized or overly drawn out. Perhaps. However, as we always tell both our under- graduate and post-graduate students, mastery is always mas- tery of the basics, no matter what profession one is practic- ing. And, as teachers working with students all over the U.S. and Western Europe, we find repeatedly that the problems practitioners have with prescribing Chinese herbal medicine are most often due to a breakdown in understanding some part or piece of this process. We want to be absolutely cer- tain that readers at all levels of experience understand how and why the successful prescription of Chinese herbal medi- cine is based on this very clear, logical, and specific process. For those of you who feel this information is already well digested, we beg your indulgence. And who knows, even for the seasoned practitioner, there may be a new kernal of truth that is useful. Finally, we must say a word about terminology. As in most Blue Poppy books, we have mainly used A Practical Dictionary of Chinese Medicine by Nigel Wiseman and Feng Ye as our standard for technical words with clinical implica- tions. While attempting to make the book as accessible and friendly a read as possible, our support of this terminology is based on its precision relative to the Chinese language from which our medicine springs and the fact that any given word can, using this text, be traced back to its Chinese char- acter and all the clinical implications of that character. There simply is no other English language glossary that offers us such precision. We hope that readers, whether students, new practitioners or seasoned professionals, find this book a welcome addition The Successful Chinese Herbalist Preface vii
  8. 8. to their herbal medicine library. As always, we welcome your suggestions on how we might improve our efforts when the time comes for a reprint of this book. It is our desire, with this and every book we publish, to help all students and practitioners of this medicine to be more effective clinically, more successful financially, and more satisfied personally. Thanks for reading, Honora Lee Wolfe Bob Flaws March 2005 Preface The Successful Chinese Herbalist viii
  9. 9. The origins of Chinese herbal medicine Standard professional Chinese medicine, or what is often called Traditional Chinese Medicine (TCM) in the West, is a specific style of Chinese medicine. Although standard profes- sional Chinese medicine has its roots in the Warring States, Qin, and Han dynasties, as a self-conscious style it was creat- ed in the People’s Republic of China during the 50s, 60s, and 70s. While this last fact has produced some detractors who believe its origins to be 20th century Communist materialism, modern professional Chinese medicine actually incorporates all of the best of both professional and folk medicine surviv- ing in China from its beginnings. In terms of theory, howev- er, it is primarily based on the highly literate and rational approach to medicine of the ru yi or Confucian scholar-doc- tors going back to the Han dynasty but whose writings became preeminent in later dynasties. These scholar-doctors were, by and large, fang ji jia or herbal practitioners and the administration of internal herbal medicinals was their main modality. Thus, modern professional Chinese medicine’s defining methodology was developed specifically for the prac- tice of herbal medicine. CHAPTER1 The Importance of Pattern Discrimination in Crafting the Best Formula 1
  10. 10. According to Chinese texts, the defining methodology of standard professional Chinese medicine as a specific style of Chinese medicine can be summed up in the words bian zheng lun zhi. This means basing treatment primarily on the dis- crimination of patterns. Understanding patterns & diseases The first chapter of this book is a treatise on the process of pattern discrimination and the logical procedure we follow with each patient in order to arrive at the correct Chinese herbal formula and treatment plan. For some readers this information may be a review. However, we include this some- what lengthy exposition because it is the foundation upon which good Chinese herbal medicine is always based. Also, as teachers interacting with students all over the U.S. and Western Europe, we find repeatedly that the problems stu- dents and practitioners have with prescribing Chinese herbal medicine are not necessarily because they do not know their herbs or formulas, but more often due to a breakdown of SAME DISEASE DIFFERENT PATTERNS, PART A Disease Diagnosis Hypertension Disease Hypertension is defined by a BP > 140/90mm/Hg. May be asymptomatic. Hypertension Pattern A Liver Kidney Yin Vacuity Symptoms: Dizziness, tinnitus, blurred vision, heart palpitations, BP > 140/90mm/Hg, dry mouth, PM malar flushing, fine, bowstring pulse Female: Ectomorph, 50 years old Male: Endomorph, 40 years old Hypertension Pattern B Phlegm Fire Harassing Above Symptoms: Head distention, nausea, chest oppression, profuse dreams, profuse phlegm, bitter taste in the mouth, BP > 140/90mm/Hg, slippery, bowstring rapid pulse 2 Chapter 1 The Successful Chinese Herbalist
  11. 11. understanding somewhere in this process. Thus, we present as clear an explanation of the process of diagnosis and treatment as we can, with an emphasis on potential sources of confu- sion that we have heard from our students. Those of you who feel this information is already well digested may only require a quick read of this section. However, as most seasoned practi- tioners know, review is always useful, and you might even pick up a morsel or two that help you treat your next patient more effectively. For every reader at all levels of experience, that is our sincere hope. In Chinese, the word for pattern is zheng. A pattern is the total constellation of a patient’s signs and symptoms as gath- ered by the four examinations, including tongue and pulse signs. A disease or bing, on the other hand, is made up of a smaller group of symptoms which are believed to define that disease in all persons with it. Such disease-defining signs and symptoms are a disease’s pathognomonic signs and symptoms or those by which it is specifically known. Thus, while a dis- ease usually has a narrow definition of specific signs and symptoms, a pattern is the entire holistic gestalt of the patient. This includes objective signs and subjective sensations beyond those which are strictly pathognomonic of the patient’s dis- ease. In general, a disease’s pathognomonic signs and symp- toms only account for a percentage of the patient’s entire pat- tern as seen by Chinese medicine. Everyone with a certain disease must display certain key signs and symptoms before they can be diagnosed with that dis- ease. For instance, patients with measles must display a char- acteristic rash, whereas patients with chicken pox must dis- play characteristic pustules. However, a person with a disease may also display a large number of other idiosyncratic signs and symptoms. In Chinese medicine, these additional vari- able signs and symptoms are indications of the patient’s con- stitution, their relationship of righteous to evil qi, and their idiosyncratic response to the disease. Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 3
  12. 12. Most systems of medicine, including other styles of non-TCM Chinese medicine and modern Western medicine, primarily base their treatment on the diagnosis of diseases. As a matter of fact, our first acupuncture teacher taught a disease-based treatment system. Two patients with certain key, pathogno- monic signs and symptoms are diagnosed as suffering from the same disease, whether this be systemic lupus erythema- tous or rheumatoid arthritis, measles or chicken pox, divertic- ulitis or appendicitis. Based on this disease diagnosis, these two patients are then given the same treatment because they suffer from the same disease. The problem with this approach is that it does not take into account the patient’s constitution, the relationship of their righteous to evil qi, or their idiosyncratic response to the dis- ease. Thus two people with the same disease may be given the same medicine, with one getting better and flourishing, while the other may fail to get better and develops all sorts of side effects. In the latter case, this is because only the abstract con- cept of the disease was addressed and not the totality of the actual patient with that disease. DIFFERENT DISEASE, SAME PATTERN Disease A GERD Same Pattern Liver-spleen- stomach disharmony with depressive heat counterflowing upward Disease B Sinusitis 4 Chapter 1 The Successful Chinese Herbalist
  13. 13. Standard professional Chinese medicine also begins with a disease diagnosis. In contemporary professional Chinese med- icine, that disease diagnosis may either be based on tradition- al Chinese disease categories, such as mounting, strangury, and welling abscess, or on modern Western disease categories, such as bronchial pneumonia, cerebroma, or lipoma. However, the Chinese medical practitioner also makes a pat- tern discrimination and, in fact, emphasizes this pattern dis- crimination as the primary basis for treatment. Thus the famous dictum of Chinese medical methodology states: Yi bing tong zhi Tong bing yi zhi Different diseases, same treatment Same disease, different treatments What this means in Chinese medicine is that two patients with the same disease will receive two different treatments if their patterns are different. While two patients with different Female: office worker, 55 years old SAME DISEASE, DIFFERENT PATTERN, PART B GERD Patient 1 GERD Patient 2 Esophageal reflux Pattern A Large appetite constipated, loud voice, irritable 5 Esophageal reflux Pattern B Poor appetite loose stools, fatigued, soft voice Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 Male: works outside, 40 years old
  14. 14. diseases will receive the same treatment if their patterns are the same. This is the first fundamental thing to remember about the practice of professional Chinese medicine. Although it is important to make a disease diagnosis and to take the typical course of a disease and its peculiar characteristics into account, in standard professional Chinese medicine, it is more important to treat the pattern than the disease. If one only sees the disease, it is like failing to see the forest for the trees. The disease is merely a figure within the ground of the total gestalt or pattern that is the patient. Therefore, the first step in writing a Chinese herbal prescription in standard professional Chinese medicine begins with a pattern discrimi- nation. Almost without exception, when Western practitioners ask me what formula to use for their patient, they give me a disease diagnosis. Although that is the proper approach in modern Western medicine and its cousins, chiropractic and naturopathy, it is not the methodology of professional Chinese medicine. Thus, we must first discuss making a Chinese medical pattern discrimi- nation as the primary necessary prerequisite for discussing how to write a Chinese herbal prescription. In standard professional Chinese medicine, only arriving at a correct pat- tern discrimination rationally results in a cor- rect treatment plan. The Four Examinations Looking, Listening/Smelling, Questioning, Palpation This information is organized in the following way: Chapter 1 The Successful Chinese Herbalist 6 Signs & Symptoms Tongue Signs Pulse Signs
  15. 15. Making a pattern discrimination In standard professional Chinese medicine, only arriving at a correct pattern discrimination rationally results in a correct treatment plan. Since professional Chinese medicine bases its treatment primarily on the patient’s personal pattern, it is imperative that this discrimination be as accurate as possible. At present, only information gained by the four (methods of) examination can be used to establish a Chinese medical pat- tern discrimination. These four are looking, listening/ smelling, questioning, and palpation. However, when compar- ing patterns to each other, one mostly compares the A) signs and symptoms, B) tongue signs, and C) pulse signs. Thus the information gathered by the four examinations is typically organized into three groups of information. It is the comparison of the total gestalt of signs and symptoms, tongue, and pulse which make up a pattern. These can be spo- ken of as the pathognomonic or ruling markers defining a pat- tern and differentiating it from all other patterns. For instance, Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 7 1. Eight principle pattern discrimination (ba gang bian zheng) 2. Five phase pattern discrimination (wu xing bian zheng) 3. Viscera & bowel pattern discrimination (zang fu bian zheng) 4. Channel & network vessels pattern discrimination (jing luo bian zheng) 5. Qi & blood pattern discrimination (qi xue bian zheng) 6. Fluid & humor pattern discrimination (jin ye bian zheng) 7. Disease cause pattern discrimination (bing yin bian zheng) 8. Six aspect (or divisions) pattern discrimination (liu fen bian zheng) 9. Four aspect (or divisions) pattern discrimination (si fen bian zheng) 10. Three burner pattern discrimination (san jiao bian zheng) 10 Types or Subsystems of Pattern Discrimination
  16. 16. in liver depression qi stagnation (gan yu qi zhi), the signs and symptoms may include chest oppression, frequent sighing, belching and burping, irritability, a darkish tongue with normal tongue fur, and a bowstring or wiry pulse. Whereas, in liver channel depressive heat (gan jing yu re), there may be many of these same signs and symptoms but there will also be differ- ences. In this case, there will not only be belching but acid regurgitation. There will not just be irritability but even irasci- bility. The tongue will tend to be red with swollen edges and yellow fur, while the pulse will be bowstring and rapid. It is these different signs and symptoms that discriminate liver depression qi stagnation from liver channel depressive heat. In standard professional Chinese medicine, there are 10 types or subsystems of pattern discrimination. Each of these subsys- tems has their own patterns with their own criteria and pathognomonic signs and symptoms. In clinical practice, however, elements of patterns from one subsystem are typi- cally combined with elements of another subsystem. For example, if a patient is discriminated as suffering from liver blood vacuity, this complex pattern is made up from elements of three of the above subsystems. Because the pattern is pri- marily associated with the liver, it is partially based on viscera and bowel pattern discrimination. Because it involves the blood, it is also partially based on qi and blood pattern dis- crimination. And because it involves vacuity, it likewise is par- tially based on eight principles pattern discrimination. Chapter 1 The Successful Chinese Herbalist 8 Qi & Blood Pattern Discrimination Viscera & Bowel Pattern Discrimination Eight Principles Pattern Discrimination PATTERN SUBSYSTEMS FOR LIVER BLOOD VACUITY
  17. 17. New practitioners are often confused as to which set of pat- terns to use in their discrimination of a particular patient. In Chinese medicine, one uses whatever combination of pattern discrimination matches the entirety of the patient’s signs and symptoms most closely. In other words, one uses whichever one(s) fit the patient at hand. None of these sub- systems of pattern discrimination is any better than any other. Each are like tools hanging on a workbench. If a cer- tain job calls for a hammer, one uses a hammer. If another job calls for a screwdriver, one uses a screwdriver. Neither a hammer nor a screwdriver is intrinsically better than the other. However, one may work better for the job at hand. It is the same with Chinese medical subsystems of pattern dis- crimination. One should use whatever system most accu- rately describes their patient without any value judgements about the intrinsic merits of each. For instance, many patients at the onset of the common cold are best described by warm disease theory, in which case a wind heat contraction with fever and sore throat may be seen as the defensive aspect or division of the four aspects pattern discrimination subsystem. However, the same patient who was first diagnosed according to warm disease theory may also be diagnosed several days later according to six divisions pattern discrimination if they exhibit alternating fever and chills with loss of appetite and fatigue. Later, that same patient may be discriminated as suffering from lung yin vacuity as their disease runs its course. This diagnostic label is a mixture of viscera and bowel and eight principles pattern discrimination. Yet this is in no way an inconsistency in the use of these systems. Each sub- system is merely made up of patterns of signs and symptoms and the goal is to find one or more patterns which accurately describes one’s patient at that moment in time. Thus these patterns are only pragmatic tools to help in provid- ing discriminating treatment to individual patients. If one goes to a department store and tries on several brands of clothes, one Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 9
  18. 18. may find that a size six in one brand is the same as a size seven in another. Within a single brand, a size six may be right and a size seven be wrong, but that in no way invalidates that in a dif- ferent brand (or system) a size seven might be right. The benefits of this methodology Because this methodology treats each individual as an individ- ual and also treats the entire gestalt of that person’s being, its treatments are both safe and effective. Side effects are the result of not taking into account the idiosyncracies of an individual patient when prescribing. Although a certain medicine should, in theory, treat a certain disease in all people, because of indi- vidual differences in constitution as well as righteous and evil qi, some patients may tol- erate that medicine and some people may become further imbalanced by it. If we know the Chinese med- ical description of a medici- nal and the patient’s pat- tern discrimination, then we should have a good idea of whether that medicinal will cause side effects or not, what those side effects will be, and whether or not those side effects are acceptable given the dura- tion of that medicinal’s expected length of administration. This system, when done well, should produce few if any side effects. Practitioners of Chinese medicine do not believe that, when it comes to medical treatment, it is alright to rob Peter to pay Paul. In Chinese medicine, the entire organism is seen as an interdependent whole. Side effects are a sign that a medici- nal has caused an imbalance in a tissue, organ, or function. Chapter 1 The Successful Chinese Herbalist 10 If we know the Chinese med- ical description of a medicinal and the patient’s pattern discrimination, then we should have a good idea of whether that medicinal will cause side effects or not, what those side effects will be, and whether or not those side effects are acceptable given the duration of that medicinal’s expected length of administration.
  19. 19. Such side effects contradict Chinese medicine’s holistic view of the body as a totally integrated organism. In addition and as said above, a medicinal that works in one patient may not work in another. If I know the Chinese med- ical description of a given medicinal, I can also know in who it will work and why it works when it does. This is because a given medicinal must work within a real-life, individual human being and must work in coordination with the patient’s own metabolism. The predisposition of the patient’s metabolism is described by the Chinese medical pattern dis- crimination. Hence this methodology of basing treatment on each patient’s personal pattern discrimination is not only safer but tends to be more effective than a purely disease- based prescriptive methodology. Further, this methodology allows a practitioner to rationally explain to the patient why they got ill and the impact of their diet and lifestyle on the course of their illness. Patterns in Chinese medicine are based not only on empirical observation the way homeopathic patterns are. They are also based on theo- retical concepts regarding disease causes and disease mecha- nisms. The name of every Chinese medical pattern implies a dis- ease mechanism. For instance, if a patient is diagnosed as suffer- ing from an external contraction of wind heat, the practitioner can counsel the patient to avoid drafts and getting chilled, avoid eating hot, spicy food, and avoid taking acrid, warm medicinals. Thus the patient is enlightened as to the cause of their disease and what they can do about its course. This empowers the patient and helps them participate in and take responsibility for their treatment. Problems we encounter when doing a pattern discrimination In our experience, Western practitioners commonly encounter several problems with this system of pattern dis- crimination. Certainly I encountered these problems myself Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 11
  20. 20. as a young practitioner. First, because most of us must learn this system in translation, it’s easy for us to miss the associa- tions and cues which exist in Chinese. What do I mean by this? A single Chinese word often has more than one meaning or connotation, each meaning hav- ing potential clinical implications that are difficult to capture when translated into a single English term. For instance, if I see the term ni tai translated as a “smooth tongue fur,” which it is in some texts, I will not necessarily understand that this tongue coating is associated with an accumulation of dampness because the word “smooth” in English has no such connotation. Whereas, if this word is translated as “slimy tongue fur,” which it also is in some texts, and I know how the tongue fur is created according to Chinese medical theory, this immediately should make logical connections with dampness and turbidity. Similarly, if I see the words ru mai translated as a “soft pulse,” I may not understand this pulse’s relationship to the accumulation of dampness. In this case, the alternate translation of “soggy” or “sodden” pulse makes that association with the relevant disease causes and disease mechanisms easier to understand. In Chinese, all these vari- ous associations are inherent within the words. Secondly, no one Chinese medical textbook, whether in Chinese or English, is categorically complete when it comes to signs and symptoms associated with patterns. Each author tends to give a selection which they think most important or to simply write down what comes to mind first. Therefore, dif- ferent authors give slightly different lists of representative signs and symptoms for the same patterns. If a Western stu- dent or practitioner has access to only a single textbook, they frequently are not aware of the wider range of signs and symp- toms possibly associated with a given pattern. And third, many English language translations of Chinese medical books fail to translate either fully or accurately the Chapter 1 The Successful Chinese Herbalist 12
  21. 21. sections on disease causes and disease mechanisms. This infor- mation is what allows a practitioner to have an in-depth understanding of how each sign and symptom in their patient got there and, as such, is vital to our clinical thought process. Incomplete or faulty translation of this information may be due to a variety of reasons. As discussed above, since a single Chinese word may have several meanings, more than one of which has clinical significance, it can be difficult to render the often technical and abstruse language into what the translator perceives as meaningful English. Faced with this dilemma, the translator must choose one word which seems most suitable to them in the context at hand, leaving the other possible mean- ings out of the translation altogether. Further, some Western- oriented Chinese translators have told us they are concerned that the traditional Chinese concepts will look silly to Western medical professionals and so leave out sections they think will be unacceptable, write what they think a Western professional will find believable, or gloss them only briefly. Why are disease causes and mechanisms so important to us? Because, if one understands the disease mechanisms at work within a given pat- tern, one can posit, in the light of Chinese medical theory, what impact these mechanisms will have on the tongue, pulse, and various functions and tissues of the body. In this case, we are not dependent upon lists of symptoms appearing in textbooks which are never totally comprehensive or cate- gorically complete. Rather, we can account for particular signs and symptoms in our individual patient based on Chinese medical disease cause-disease mechanism theory. It is an understanding of disease causes and mechanisms that allows Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 13 If one understands the disease mechanisms at work within a given pattern, one can posit, in the light of Chinese medical theory, what impact these mechanisms will have on the tongue, pulse, and various functions and tissues of the body.
  22. 22. us to think flexibly and intelligently within the Chinese para- digm of patterns. However, in order to do this, a practitioner must constantly keep in mind like their own name, address, and phone number all the fundamental statements of fact of Chinese medicine. For example, if I know without hesitation that the breast is circulated primarily by the stomach and liver chan- nels, I can further logically deduce that distention and pain of the breasts may be a possible symptom of liver depression qi stagnation, even if my main textbook does not happen to mention this. Further, in order to be perfectly clear about this, I must know that the liver is in charge of coursing and discharging and that, when the liver is replete, it often in- vades the stomach via the control cycle of five phase theory. In addition, when I remember that the liver stores the blood, that the chong mai is the sea of blood, that the chong mai is one of the two most important vessels controlling menstruation, and that the chong mai connects with the stomach channel at Qi Chong (St 30), then I can account for the fact that breast distention and pain typically occurs prior to menstruation even though only specifically gyne- cological texts mention this symptom under liver depression qi stagnation. In other words, in professional Chinese medicine, all the vari- ous facts we were asked to learn by heart in our introductory classes on Chinese medical theory become the sentences we use to describe what is going on in our patients. These facts become the propositions in the logical syllogism we create to prove to ourselves that we have arrived at the right conclu- sions about each patient. As a young practitioner, I did not think this level of memorization was vital. However, it was also my experience that when I went back and actually com- mitted these statements of fact to the deepest part of my heart and mind, that was when I truly began to be able to practice this medicine with confidence and reliable success. Chapter 1 The Successful Chinese Herbalist 14
  23. 23. Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 15 Statement #1. The breast is circulated by stomach (foot yang ming) and liver (foot jue yin) channels. Statement #2. The liver is in charge of the coursing and discharge of qi. Statement #3. When the liver is depressed and its qi stagnant, it cannot do its function of coursing and dis- charging. It may become replete and hot. Statement #4. When the liver is replete, it may invade the stomach. Statement #5. The liver stores the blood. Statement #6. The chong mai is the sea of blood. Statement #7. The chong mai and ren mai control men- struation. Statement #8. The chong mai connects to the stomach channel at Qi Chong (St 30). Statement #9. If the liver is depressed and its qi is stag- nant, qi may then become stagnant in the breast via the liver channel and the stomach channel, and the blood in the chong mai may become static. Since the chong and ren rule menstruation, these symptoms are likely to become worse during the build up of qi and blood in the lower burner prior to menstruation. Statements of Fact Explaining Premenstrual Breast Distention and Pain Due to Liver Depression Qi Stagnation
  24. 24. That being said, the other single most important thing that we can say about making a Chinese medical pattern dis- crimination is that no sign or symptom should be omitted simply because it does not seem to fit one’s preconceived ideas about the patient’s disease diagnosis. In the process of making a pattern discrimination, signs and symptoms gath- ered first often suggest a particular pattern to the practi- tioner. However, as we gather more signs and symptoms, some of these may not fit with our preconceived ideas about that pattern. In this case, we must think more deeply about the pattern discrimination and the dis- ease mechanisms that could cause it until we come up with a pattern discrimina- tion whose mechanisms do account for all the patient’s signs and symptoms, per- plexing and seemingly con- trary or not. Patients may, of course, require more than one pattern to describe their situation. While Chinese medical textbooks make it seem like patients exhibit very simple, discrete pat- terns, these single, neat diagnostic boxes or categories are merely teaching devices designed to highlight the differ- ences between patterns. In real-life clinical practice, patients do not tend to manifest a single, textbook perfect, discrete pattern but rather a combination of elements of two, three, or even more patterns. In fact, based on my more than 20 years experience, I [BF] would say that most Western patients with the chronic diseases that tend to be our bread and butter in the world of alternative care display not less than three patterns and often as many as seven or eight simultaneously! Chapter 1 The Successful Chinese Herbalist 16 It was my experience that when I went back and actually committed these statements of fact to the deepest part of my heart and mind, that was when I truly began to be able to practice this medicine with confidence and reliable success.
  25. 25. Reframing your patients’ experience In trying to unravel such a tangled skein of signs and symp- toms, it is once again very important to first record the patient’s signs and symptoms as completely and accurately as possible. This means sharpening one’s abilities to see, hear, smell, question, and feel. In particular, one must ask questions which are designed to reframe the patient’s experience into the terminology of Chinese medicine. For instance, if the patient is asked how their bowel movements are, they may say they are constipated. This can mean different things to different people. It is imperative that the practitioner clarify exactly what the patient means by this. Does it mean they do not have a bowel movement every day? Do they mean that defecating is difficult or uncomfortable? Or does it mean that the stools are hard and bound? Each of these different descriptions may potentially mean something different in terms of Chinese medical disease mechanisms and pattern discrimination. Or a patient may say that they are depressed. This does not necessarily mean the same thing in Chinese medicine as it does in everyday English. Does the patient mean that they feel chest oppression, irritability, and frustration, or does it mean that they feel listless, fatigued, and cannot get out of bed? The difference between these two sets of symptoms is the difference between a correct and incorrect pattern dis- crimination. It is true that Chinese tend to somaticize their complaints and Western patients tend to psychologize theirs. Therefore, Western practitioners attempting to do Chinese medicine with Western patients must constantly keep in mind and also point out to their patients that all emotional experiences are simultaneously physically felt experiences. As Westerners, we tend to conceptualize and describe our feelings with abstractions: “I feel happy,” “I feel sad,” “I feel anxious,” etc. Yet each of these abstract con- cepts are accompanied by (or are names we give to) physical feelings and sensations. We will have an easier time with pattern discrimination if we train ourselves and our patients Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 17
  26. 26. to reconnect with these physical feelings in order to match up their complaints with Chinese, somaticized, pattern-dif- ferentiating signs and symptoms. Mastery of pulse diagnosis There is no shortcut to honing one’s Chinese medical ability to gather accurate information via the four examinations. It sim- ply takes time to sharpen these abilities. In particular, it may take years to really learn to read the pulse. Learning the pulse means developing the ability to consciously and consistently discriminate all of the 28 pulses. In my experience, simply knowing nine or 10 pulses—fast and slow, floating and sunken, bowstring, fine, or slippery—is not enough to do an accurate Chinese medical pattern discrimination on a complicated patient. In our typical patient population in the West, it is use- ful if not vital to be able to identify the surging, moderate/ retarded, scattered, sodden/soggy, choppy, drumskin, scattered, short, and vacuous pulses at the least. In order to learn these, my experience says that we simply have to memorize their Chinese medical definitions verbatim and keep these in mind when feeling the pulse. Let’s again take the soggy pulse as our example. The definition of the ru mai or sodden/soggy pulse is that it is floating, fine, and soft or pliable. If I write down on the chart that the patient’s pulse is floating, fine, and soft but do not recognize this as the verbatim definition of the soggy pulse, I will not necessari- ly associate this with the disease mechanisms associated with the soggy pulse. Although this ability is, in my experience, largely a function of time and maturation which cannot be rushed, it cannot even begin until the word for word defini- tions of the pulse images are committed to memory. When we have done this small amount of memorization, we have a bet- ter chance of being able to accurately describe what we feel under our fingers and to connect it with clinically meaningful disease mechanisms. In the welter of all we must remember to graduate from school, these definitions are easily forgotten Chapter 1 The Successful Chinese Herbalist 18
  27. 27. once the exam for that class is passed. The good news is that this information is still available and we can go back and learn it again, as if we were re-loading the operating system on our computer to make sure it is working at optimal capacity. Further, it’s important to realize that modern Chinese medi- cine has tended to downplay the pulse and to oversimplify its teaching. For instance, Hua Tuo, in his Zhong Zang Jing (Classic of the Central Viscera), says over and over again that the slippery pulse is a vacuity pulse. Likewise, Zhu Dan-xi, in his Dan Xi Zhi Fa Xin Yao (The Heart & Essence of Dan Xi’s Methods of Treatment), says that the bowstring pulse is also a vacuity pulse. This is contrary to modern Chinese textbooks, but a vital piece of information when trying to understand chronically ill, complicated Western patients who often exhibit slippery, bowstring, surging, or floating pulses, all of which can be associated with counterflow inversion and underlying vacuity. Thus, in studying the pulse, it is more than a little helpful to study premodern Chinese texts as well as the modern literature available on this subject. The arithmetic of pattern discrimination Although I have heard some Western teachers of Chinese medicine say that the practitioner should “go with their gut feeling or intuition” about their patients’ patterns, my Chinese teachers have all stressed that unraveling complicated patterns is based on very clear logic. In fact, doing a Chinese med- ical pattern discrimination is something like a mathe- matical problem, in that it is an additive process. When we work on a math problem, we are not allowed to simply leave out one or two of the numbers Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 19 . . . doing a Chinese medical pattern discrimination is something like a mathemati- cal problem, in that it is an additive process. When we work on a math problem, we are not allowed to sim- ply leave out one or two of the numbers because it might make the problem easier to solve!
  28. 28. because it might make the problem easier to solve! Similarly, as mentioned above, we must be able to account for every sign and symptom in our pattern discrimination, without leaving out the ones that do not fit our initial hypothesis or that we cannot initially understand. For example, if the patient’s tongue is red, this invariably signifies heat, at least in the upper burner since the tongue is in the upper burner. If the tongue fur is dry and yellow, the yellow signifies heat affecting the stomach qi and the dryness signals injury to stomach fluids. If the tongue is also fat with teeth-marks on its edges, this suggests an accumulation of body fluids. Since the spleen is the primary viscus in charge of the transporta- tion and transformation of body fluids, this fatness and flut- ing suggest spleen vacuity and dampness. Thus an analysis of the tongue signs alone suggest that the patient is suffering from an element of heat causing drying of the stomach with a concomitant accumulation of dampness. All this can be and needs to be corroborated and further clarified by the pulse and other general signs and symptoms. For me, it also helps to remember that very few symptoms can be ascribed a single, universal meaning. All but a handful of signs and symptoms may be the result of more than a single dis- ease mechanism. When analyzing and ascribing meaning to any sign or symptom, that sign or symptom must be seen in relation- ship to all other signs and symptoms. For instance, night sweats are commonly due to yin vacuity and vacuity heat forcing fluids out of the body during the night which is ruled by yin. However, night sweats may also be due to heart blood vacuity, spleen vacuity with accumulation of dampness, and half interior-half exterior invasion of external evil qi. Further, a person may have yin vacuity and vacuity heat that is due to persistent damp heat with concomitant heart blood and spleen qi vacuity and damp- ness. Which of these mechanisms are operative in a given patient is determined by the total constellation of their signs and symptoms. But unless we can determine with accuracy which patterns we are treating, our treatment of the patient will be Chapter 1 The Successful Chinese Herbalist 20
  29. 29. Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 21 Hallelujah Symptoms While typically no one sign or symptom always indicates a single pattern in Chinese medicine, there are exceptions to every rule. The following is a list of our “Hallelujah Symptoms.” These are the handful of signs and symptoms in Chinese medicine which do only indicate a single pattern. For instance: Fatigue - spleen vacuity Drowsiness after eating - spleen vacuity Dizziness standing up - spleen vacuity A fat, enlarged tongue - spleen vacuity Easy bruising - spleen vacuity A bitter taste in the mouth - liver-gallbladder heat Irritability - liver depression Rib-side pain - liver depression Sores on the lips - stomach heat Rapid hungering, large appetite - stomach heat Abdominal distention - qi stagnation Sighing - qi stagnation Night blindness - blood vacuity When we say that these signs and symptoms only indicate a sin- gle pattern, we are not talking about disease mechanisms, nor are we talking about the complicated evolutions of these simple patterns. For instance, while lip sores always indicate stomach heat, stomach heat may be complicated by lung heat and/or heat toxins. While irritability always indicates liver depression, such depression may be associated with depressive heat, phlegm, phlegm heat, blood stasis, blood vacuity, qi vacuity, or even external contraction of wind evils. And, although text- books typically say a fat, enlarged tongue indicates the accumu- lation of water dampness, since the spleen is averse to and dam- aged by dampness, if there is dampness causing an enlarged tongue, there will be spleen vacuity. Similarly, although fatigue is, ipso facto, a symptom of spleen qi vacuity, this may be due to and may result in phlegm damp encumbrance.
  30. 30. inaccurate a certain percentage of the time. Intuition and gut feelings may or may not help us, but a thorough knowledge of patterns and disease mechanisms will give us the surety to diag- nose and prescribe with reasonable precision for each suffering individual who sits before us asking for our care. This means that the mecha- nism associated with any sign or symptom must be corrobo- rated by related signs and symptoms. In the case above, if the pulse is rapid and slip- pery instead of fine, if the tongue fur is yellow and glossy instead of scant and dry, and if there is urinary urgency with burning, turbid, yellow urine, these signs and symptoms all suggest something other than or in addition to yin vacuity. We all want to be clinically successful and do the best job for our patients. With that in mind, we cannot stress enough the importance of first accurately gathering signs and symptoms, then analyzing them individually, and eventually synthesizing them to reveal their Chinese medical meaning. To use an exam- ple already given above, a bowstring or wiry pulse most com- monly indicates liver depression qi stagnation, more commonly abbreviated to just liver qi. A bowstring pulse plus a rapid pulse equals heat plus stagnation. Just in that way, we first take apart all the individual signs and symptoms and then add the indica- tions back up again to arrive at what is most commonly a com- plex, multifaceted pattern discrimination. However, the difficult part is that, at the same time, the meaning of each individual sign or symptom is dependent upon the total constellation of signs and symptoms seen in relationship to each other. So the parts of the puzzle that each patient presents must be teased Chapter 1 The Successful Chinese Herbalist 22 Intuition and gut feelings may or may not help us, but a thorough knowledge of patterns and disease mechanisms will give us the surety to diagnose and prescribe with reasonable precision for each suffering individual who sits before us asking for our care.
  31. 31. apart and then analyzed both separately and together to find their clinical meaning. Very commonly in the West, our patients suffer from complex, recalcitrant diseases. As practitioners of a foreign, alternative sys- tem of medicine, our patients typically come to us after having tried numerous other practitioners and systems of treatment. Thus the easy or self-limiting cases are often winnowed out before they make it to our doors. To make matters worse, previ- ous treatment itself may have caused iatrogenic complications, making the case even more difficult to unravel. This is especially the case if the patient is still taking one or more Western, Ayurvedic, homeopathic, and/or naturopathic medicines from some other practitioner(s). [See Chapter 12 for more on this sub- ject.] In this case, we may have a hard time knowing what is the patient’s underlying condition and what is a manifestation of the medication. Thus, it is not uncommon to come across patients with hot above and cold below, a hot, dry stomach and vacuous or cold, damp spleen, damp heat in their large intestine and vacuity cold affecting their kidneys, or heat and dampness mutually binding with qi and blood stasis and stagnation at the same time there is kidney yang vacuity and cold below and yin vacuity and heat above. Such complex presentations are com- mon in our clinics here in the West and yet they would present a challenge to even the best Chinese practitioner with many years of experience! Upon graduation from five years of medical school, Chinese practitioners are assigned to a large clinic or hospital. There they are given only patients whose diseases are commensurate with their level of knowledge and experience. In addition, there are always senior practitioners to give advice and critique and cor- rect the young practitioner’s diagnosis and treatment. This allows practitioners in China to develop their skill and knowl- edge slowly and in a relatively supportive environment. Here in the West, Chinese medical education is still in a developmental stage. It is shorter than what is required in China and has a far Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 23
  32. 32. more limited clinical component. Upon graduation, the most common practice scenario in the West is a private, single practi- tioner clinic, without mentoring or clinical support. If the first patient who knocks on our door after setting out our shingle is someone with cancer, MS, or AIDS, how can we be expected to understand these cases? Such patients tend to have complicated, multifaceted, seemingly contradictory patterns and, in a Chinese clinic, would be sent to the senior practitioners with decades of clinical experience and knowledge. For the reasons listed above, Western practitioners often require more knowledge and insight in treating patients than their Chinese peers. And yet, our educational system as cur- rently designed cannot always start us off with all the skill and knowledge we need. One way to improve this situation is to read as widely in the literature on our own as possible. On the one hand, for the bravest souls this means studying med- ical Chinese, since the overwhelmingly bulk of the literature exists only in Chinese and will, for a variety of reasons, never be translated into English. On the other hand, I personally have found the theories contained in Li Dong-yuan’s Pi Wei Lun (Treatise on the Spleen & Stomach) to be the single most helpful book in clarifying the contradictory but interrelated mechanisms so often at work in our American patients. This book goes beyond where modern Chinese textbooks leave off and, even in China, practitioners are renewing their interest in this book as containing many of the answers necessary to treating complicated cases involving allergic hyperimmunity, autoimmunity, hypoimmunity, endocrine dyscrasia, and chronic, polysystemic candidiasis and intestinal dysbiosis. Using treatment principles to improve our results In Chinese texts, it is said that the treatment principles or zhi ze are the bridge between the pattern discrimination and the treatment or formula. In Chinese books and journals, after the pattern discrimination there always comes a statement of treatment principles. These are theoretical statements about Chapter 1 The Successful Chinese Herbalist 24
  33. 33. what needs to be done in order to rectify the imbalance implied by the name of the pattern. As such, they help to lead us to the correct chapter in our formula textbook. Such treatment principles are couched in the technical language of Chinese medicine and only certain principles are agreed to be the correct principles for the treatment of particular patterns. For instance, if a patient’s pattern discrimination is liver depression qi stagnation, the requisite and usual treatment principles for remedying this imbalance are to course the liver, rectify the qi, and resolve depression. Whereas, if a patient is discriminated as suffering from external contraction of wind heat, the treatment principles are to resolve the exte- rior, diffuse the lungs, and clear heat using acrid, cool medici- nals. In the latter case as in many others, different Chinese authors may give slightly varying principles for the same pat- tern. However, when one looks at these variations more close- ly, they are mostly just different ways of saying the same thing or differences in therapeutic emphasis. For instance, in the second example above, some authors might say that external contraction of wind heat requires one to relieve or resolve the exterior, dispel wind, and clear heat. Nonetheless, although there is some latitude in stating one’s treatment principles, this latitude is circumscribed and we can say that certain treatment principles are either correct or categorically wrong for the treatment of certain patterns. Chinese medical practitioners regularly use between 200-300 treatment principles. [See Appendix II for a list of the most commonly used treatment principles.] Typically, there will be one treatment principle for each element of the pattern diag- nosis. For example, if a patient suffers from liver blood vacu- ity, one should supplement the liver and nourish the blood. Thus there is one principle for the liver and another for the blood. In this way, both elements implied by the pattern’s name are comprehensively and categorically addressed. Chinese authors most commonly write these principles in Importance of Pattern Discrimination in Crafting the Best Formula Chapter 1 25
  34. 34. four syllable groups. For instance, if a patient suffers from spleen-kidney yang vacuity, the treatment principles might be stated in Chinese, jian pi yi qi, bu shen wen yang. This means to fortify the spleen and boost the qi, supplement the kid- neys and warm the yang. As with so much of Chinese medical technical terminology, the words used in constructing treatment principles often have asso- ciations not readily apparent in translation. For instance, the word zi means to enrich and is only used in relationship to yin. Its character includes the water radical. One may come across the construction, zi shen, to enrich the kidneys. In Chinese, this implies enriching kidney yin or water (not kidney yang, kidney qi, or kidney essence). For an English-speaking practitioner to really understand the implications of these words, it helps to spend some time studying the terminology used in stating treat- ment principles and learning such technical associations which are apparent in Chinese. Most of the time, therapeutic or treatment principles are addressed to the ben or root of the imbalance implied in the pattern’s name. Sometimes, however, if biao or branch treat- ment of acute signs or symptoms must be given, this is also specified in the treatment principles. Since vomiting involves a loss of fluids, the finest essence of the digestate, and qi, vomiting is a branch symptom that, in Chinese medicine, is accorded priority or at least prominence in treatment. Therefore, if there is vomiting, one typically appends the words stop vomiting to the preceding list of treatment princi- ples. Similarly, one appends the principles of stop diarrhea for diarrhea, stop bleeding for any type of hemorrhaging, stop pain for any kind of severe pain, etc. When such branch treat- ment principles are included in a list of treatment principles, this requires that the practitioner address this symptom specifi- cally and symptomatically. This process will become clearer in the next chapter when we discuss modifications of formulas. Chapter 1 The Successful Chinese Herbalist 26
  35. 35. In Chapter 1, we’ve reviewed the basics of analyzing your patients according to the process of Chinese medical diagno- sis. In this Chapter, we move from diagnosis into the realm of treatment using Chinese herbal medicine. We continue from where we ended in Chapter 1, with the importance of treat- ment principles. Getting to the right formula category In the methodology of professional Chinese medicine in China, both the treatment principles and the pattern discrim- ination are a charting requirement. Why should this matter to us? It matters because the treatment principles help funnel us toward the correct formula and its proper modification. Using liver depression qi stagnation again as our example, if a patient suffers from liver qi, the usual therapeutic princi- ples are to course the liver and rectify the qi. Once I have written those words down underneath the pattern discrimination, it then becomes crystal clear, accord- 27 In the methodology of pro- fessional Chinese medicine in China, both the treat- ment principles and the pattern discrimination are a charting requirement. CHAPTER 2 Writing a Formula That Works for Each Patient
  36. 36. ing to the logic and methodology of Chinese medicine, that I should chose a formula from the qi-rectifying category of for- mulas. In Chinese medicine, there are 20 some different categories of formulas, such as exterior-resolving formulas, phlegm-trans- forming formulas, blood-quickening formulas, blood-stopping (i.e., stop bleeding) formulas, etc. Chinese formulas and pre- scriptions texts are organized and group their formulas accord- ing to these categories. Thus the principle of rectifying the qi immediately directs me to the appropriate group of formulas from which to chose. This narrows down my choices from Chapter 2 The Successful Chinese Herbalist FOUR EXAMINATIONS SIGNS, SYMPTOMS, TONGUE, PULSE DISEASE DIAGNOSIS PATTERN DISCRIMINATION TREATMENT PRINCIPLES TREATMENT PLAN (FORMULA) CLINICAL RESULT 28
  37. 37. potentially hundreds of formulas to a much smaller, more man- ageable group. This is especially so if I stick with a repertoire of the most standard, best known Chinese medical formulas. Within the qi-rectifying category of formulas, I next look only at those formulas which course the liver, since that is the other principle stated for the treatment of liver qi. Out of the total of qi-rectifying formulas, this narrows down my choices even more. Now I have only a small handful of formulas from which to chose. If the pattern is truly this simple, I would next look for the formula which not only rectifies the qi and courses the liver but which is known through empirical expe- rience to treat the disease or signs and symptoms of the patient before me. The standard formula for this very simple scenario is Si Ni San (Four Counterflows Powder). Chai Hu (Radix Bupleuri) Zhi Shi (Fructus Immaturus Citri Aurantii) Bai Shao (Radix Albus Paeoniae Lactiflorae) Gan Cao (Radix Glycyrrhizae Uralensis) However, such a simple pattern discrimination among Westerners is the exception rather than the rule. Since liver depression qi stagnation is a species of repletion, based on five phase theory, the viscus and bowel of the earth phase are most Writing a Formula That Works for Each Patient Chapter 2 29 Formula for these Treatment Principles: Xiao Yao San Ingredients: Chai Hu (Radix Bupleuri) Bai Shao (Radix Albus Paeoniae Lactiflorae) Dang Gui (Radix Angelicae Sinensis) Bai Zhu (Rhizoma Atractylodis Macrocephalae) Fu Ling (Sclerotium Poriae Cocos) mix-fried Gan Cao (Radix Glycyrrhizae Uralensis) Bo He (Herba Menthae Haplocalycis) Sheng Jiang (uncooked Rhizoma Zingiberis Officinalis)
  38. 38. vulnerable to disease transmission. Thus, if the liver qi has led to spleen vacuity weakness complicated by blood vacuity and an element of dampness, I must find a formula which courses the liver, rectifies the qi, fortifies the spleen, eliminates damp- ness, and nourishes the blood. The most famous formula whose ingredients categorically and comprehensively accomplish all these goals is Xiao Yao San (Rambling Powder). If there are all of the above elements in the patient’s pattern discrimination, but the patient’s liver qi has become Chapter 2 The Successful Chinese Herbalist 30 Western disease diagnosis: Amenorrhea Chinese disease diagnosis: Menstruation behind schedule Symptoms: Fatigue, irritability, craves sugar, easy nausea, scanty, infrequent menstruation Pulse signs: Soggy (i.e., floating, fine, forceless), bowstring in the right guan Tongue signs: Fat with teeth-marks, pale Pattern dx: Liver depression qi stagnation, spleen vacuity and dampness with blood vacuity Treatment principles: Course the liver and rectify the qi, fortify the spleen, eliminate dampness, and nourish the blood
  39. 39. depressed to the point of transforming into heat, then one must also add the principles: clear heat and resolve depres- sion. In that case, one is directed to Dan Zhi Xiao Yao San (Moutan & Gardenia Rambling Powder) since it includes two ingredients to clear heat from the liver and the blood which the liver stores. In most formula and prescription texts, including Bensky and Barolet’s Chinese Herbal Medicine: Formulas & Strategies, this formula appears as a modification of Xiao Yao San as the standard formula. Dan Pi (Cortex Radicis Moutan) Zhi Zi (Fructus Gardeniae Jasminoidis) Chai Hu (Radix Bupleuri) Bai Shao (Radix Albus Paeoniae Lactiflorae) Dang Gui (Radix Angelicae Sinensis) Bai Zhu (Rhizoma Atractylodis Macrocephalae) Fu Ling (Sclerotium Poriae Cocos) mix-fried Gan Cao (Radix Glycyrrhizae Uralensis) On the other hand, if blood vacuity is more pronounced along with the liver qi, spleen vacuity, and dampness, then one is directed to Hei Xiao Yao San (Black Rambling Powder) since this version of this standard formula includes Shu Di (cooked Radix Rehmanniae Glutinosae) to more specifically and effectively aid Dang Gui and Bai Shao in nourishing the blood. This is also usually listed under Xiao Yao San as a mod- ification of that formula. Shu Di (cooked Radix Rehmanniae Glutinosae) Dang Gui (Radix Angelicae Sinensis) Bai Shao (Radix Albus Paeoniae Lactiflorae) Chai Hu (Radix Bupleuri) Bai Zhu (Rhizoma Atractylodis Macrocephalae) Fu Ling (Sclerotium Poriae Cocos) mix-fried Gan Cao (Radix Glycyrrhizae Uralensis) Bo He (Herba Menthae Haplocalycis) Sheng Jiang (uncooked Rhizoma Zingiberis Officinalis) Writing a Formula That Works for Each Patient Chapter 2 31
  40. 40. To review this process, it was the statement of the principle to rectify the qi that leads to the qi-rectifying category of medici- nals in this case. From there, the further principles stated lead one with ever greater precision and narrowing down of choices to the precise formula within that category. Most commonly, the key principle that leads us to the correct category of formu- las is the first principle stated or, at least, is within the first pair. In the example above, coursing the liver usually precedes the principle of rectifying the qi. This is probably just because of the way these four syllables sound to the Chinese ear. Nonetheless, it should be remembered that each principle is usually made up of two Chinese words and two such principles comprising four syllables are read as a unit. Therefore, in the case of external contraction of wind heat, resolving the exterior is the first and most important principle. This leads us to the exterior-resolving category of formulas. Clearing heat is subsidiary to that and further refines and nar- rows the search for an appropriate formula within that category. Going back to the liver, if a patient displays signs and symp- toms consistent with liver wood invading earth and a hot, replete stomach and vacuous, damp spleen, one might say that the treatment principles are to course the liver and recti- fy the qi, fortify the spleen and eliminate dampness, and clear stomach heat. However, loss of harmony between the liver and spleen and spleen and stomach can also be treated by the principle of harmonizing. In such a case, the treatment principles can also be to harmonize the liver and spleen and spleen and stomach while clearing heat from the stomach and eliminating dampness. If one states it this way, then those principles lead one to the harmonizing (he ji) category of formulas. Within that category, the standard and most famous formula which categorically and comprehensively embodies and addresses each of these principles is Xiao Chai Hu Tang (Minor Bupleurum Decoction). Chapter 2 The Successful Chinese Herbalist 32
  41. 41. Writing a Formula That Works for Each Patient Chapter 2 33 Western disease diagnosis: GERD Chinese disease diagnosis: Stomach pain Symptoms: Heartburn and acid reflux, fatigue, irritability, craves sugar, rapid hungering, bad breath Pulse signs: Fast, soggy (i.e., floating, fine, forceless), bowstring in the right bar Tongue signs: Fat with teeth-marks, red tongue body with dry, yellow fur Pattern dx: Liver-spleen disharmony, spleen dampness with stomach heat Treatment principles: Course the liver and rectify the qi, fortify the spleen, clear heat and eliminate dampness Formula for these Tx Principles: Xiao Chai Hu Tang Ingredients: Chai Hu (Radix Bupleuri) Ren Shen (Radix Panacis Ginseng) Ban Xia (Rhizoma Pinelliae Ternatae) Huang Qin (Radix Scutellariae Baicalensis) mix-fried Gan Cao (Radix Glycyrrhizae Uralensis) Da Zao (Fructus Zizyphi Jujubae) Sheng Jiang (uncooked Rhizoma Zingiberis Officinalis)
  42. 42. We know that this formula does address and embody each of these therapeutic principles by recognizing and understand- ing the Chinese medical rationale for the inclusion of each ingredient in this formula. When we know the materia med- ica well enough to immediately comprehend what each ingre- dient is meant to do in the formula, we will have no trouble understanding exactly what pattern and, therefore, what patient a formula fits. In this last example above, although the treatment principles do lead to the correct category within which to find the cor- rect formula, our theoretical understanding of Chinese medi- cine does have to be good enough to know that liver-spleen and spleen-stomach imbalances are described as bu he, lack of harmony and that, there- fore, it is necessary to pick a formula from the harmoniz- ing category. Although there are some tricky aspects to finding for- mulas within the traditional categories of formulas based on therapeutic principles in turn based on pattern dis- crimination, if our founda- tion in Chinese medical theory is sound and we have studied the formulas within each traditional category so that we have an overview of the contents of these categories, this system of selecting formulas is extremely logical, safe, and effective. As stated above, when problems exist in making this system work, they are mostly due to not understanding this system as it is understood in Chinese where the correct associations are made by the lan- guage itself. Even studying a little medical Chinese can great- ly help this situation. Such problems may also arise because Chapter 2 The Successful Chinese Herbalist 34 If our foundation in Chinese medical theory is sound and we have studied the formu- las within each traditional category so that we have an overview of the contents of these categories, this system of selecting formulas is extremely logical, safe, and effective.
  43. 43. of not being adequately familiar with the traditional cate- gories of formulas and the most important formulas within each category. Thus, if a patient’s presenting pattern discrimination is blood stasis, we then write down under that the requisite treatment principles which are to quicken the blood and transform sta- sis. These principles imply, according to Chinese medical logic, that we should look for an appropriate formula under the blood-rectifying or li xue category of formulas. Within that category, we then select a formula which quickens the blood and transforms stasis in the appropriate part of the body. For instance, Ge Xia Zhu Yu Tang (Below the Diaphragm Stasis-dispelling Decoc- tion) primarily dispels blood stasis in the hypochondral regions. Whereas, Shao Fu Zhu Yu Tang (Lower Abdomen Stasis-dispelling Decoction) is especially effective for dispelling blood stasis in the lower abdomen. Similarly, if the patient’s pattern discrimination is phlegm accumulation, then the treatment principle is to transform phlegm. Hence we should look under the phlegm-transform- ing category of formulas. If the phlegm is hot phlegm, we look for a formula that transforms phlegm and clears heat. If the phlegm is cold phlegm, we look for a formula that trans- forms phlegm and eliminates dampness. Then, within those various categories of formulas, we must also look to see that the formula has been found to be empirically effective for the Writing a Formula That Works for Each Patient Chapter 2 35 CHART WRITING PROCESS REVIEW Patient’s Major Complaint Disease Diagnosis (Both Western & Chinese) Distinguishing Signs & Symptoms, Tongue, Pulse Pattern Discrimination Treatment Principles Guiding Formula Additions, Subtractions
  44. 44. particular patient’s disease diagnosis, addresses their signs and symptoms, and especially addresses their major complaint. Once we take all these factors into account, it is hard not to arrive at a formula which fits the patient’s disease, pattern, and signs and symptoms. Writing a good Chinese medicinal formula Although the process of moving from a pattern discrimina- tion to a statement of treatment principles greatly helps in identifying the correct category of formulas in which to search, when we have found a standard guiding formula, we will still usually have to modify it in order to tailor it as per- fectly as possible to the patient’s needs. In China the practi- tioner first writes down on the patient’s chart their major complaint or already established disease diagnosis. Then comes the main distinguishing signs and symptoms including the tongue and pulse using the standard, professional, techni- cal vocabulary of Chinese medicine. These are followed by the pattern discrimination and the treatment principles. Then the practitioner writes the name of the formula. Most of the time in clinical practice, the name of the formula is modified by either of two pairs of words. Either the words jia wei, added flavors, or the words jia jian, additions and subtrac- tions, are prefixed or suffixed to the formula’s name. Added flavors mean added ingredients. Additions and subtrac- tions mean that some ingredients of the standard formula have been deleted and others which are not part of the stan- dard formula have been added. Sometimes Westerners are under the mistaken impression that, since most of the medici- nal ingredients used in Chinese internal medicine are herbs, this system is safe for that reason. However, many of these ingredients are very potent and others are used in compara- tively high doses. What makes this system safe and effective is the precision in writing and modifying formulas to fit patients as exactly as possible. If an ingredient in a standard formula is not necessary, it is just as important to take this out since it may very well cause side effects or iatrogenesis. If Chinese Chapter 2 The Successful Chinese Herbalist 36
  45. 45. herbs are powerfully good in the right situation, then it is axiomatic that they can also be powerfully bad in the wrong situation. Thus, it is just as important to delete unneces- sary ingredients as to add addi- tional ingredients when modi- fying a formula. Liu Wei Di Huang Wan (Six Flavor Rehmannia Pills) is one of the best known formulas in modern Chinese medicine. It is designed for the treatment of kidney yin vacuity. Of its six ingredients, three are supplementing to the kidneys and three are draining. Two of the draining ingredients seep and elimi- nate dampness. The third draining ingredient clears vacuity heat and heat in the blood. The ingredients of this formula are: Shu Di (cooked Radix Rehmanniae Glutinosae) Shan Zhu Yu (Fructus Corni Officinalis) Shan Yao (Radix Dioscoreae Oppositae) Fu Ling (Sclerotium Poriae Cocos) Ze Xie (Rhizoma Alismatis Orientalis) Dan Pi (Cortex Radicis Moutan) Of these ingredients, the first three are the three kidney- supplementing ingredients, and the last three are the three draining ingredients. Because the kidneys are one of the three viscera which govern water metabolism and, in particular, control urination, patients with kidney yin vacuity frequently have urinary dis- turbances. With kidney yin vacuity, we commonly expect short, frequent, yellow urination, terminal dribbling, and/or nocturia. However, not all patients suffering from kidney yin vacuity do suffer from urinary complaints. The Chinese med- ical idea of the kidneys covers a number of other tissues and Writing a Formula That Works for Each Patient Chapter 2 37 What makes this system safe and effective is the precision in writing and modifying formulas to fit patients as exactly as possible.
  46. 46. functions besides urination. If a patient is diagnosed as being kidney yin vacuous but they do not have any irregularity in their urination, the two water-seeping, dampness-eliminating medicinals are deleted in contemporary Chinese practice. Because Ze Xie and Fu Ling seep water, they can drain right- eous qi and yang. Therefore, not only can they cause fluid dryness if used unnecessarily, but they can also result in qi vacuity. In this formula, Dan Pi is meant to clear heat which may arise from supplementing kidney yin. Since kidney yin and yang are mutually interdependent, if yin is supplemented, yang may also flare up and, in particular, enter the blood aspect or division. In addition, this ingredient also quickens the blood. It is included in this formula because blood stasis is a com- mon complicating factor in the types of chronic diseases asso- ciated with kidney yin vacuity. However, quickening the blood may unnecessarily damage the blood, while clearing heat unnecessarily may damage the spleen and stomach, the postnatal root of qi and blood production, or diminish the righteous warmth of the lifegate fire, the source of all trans- formation in the body. In Chinese clinics, we may still write on a patient’s chart that the guiding formula employed was Liu Wei Di Huang Wan if only the three supplementing ingredients are used. Then, in addition, there may be another 12 ingredients added. In this case, the formula is written, Liu Wei Di Huang Wan Jia Jian (Six Flavors Rehmannia Pills with Additions & Subtractions). A new herbal practitioner looking at such a formula may find it hard to recognize the resulting formula as Liu Wei Di Huang Wan at all. Ingredients are added to standard formulas in order to A) aug- ment and amplify certain functions of the formula, B) treat disease mechanisms (i.e., complicating patterns) not covered by the standard formula, and C) to treat specific symptoms. Chapter 2 The Successful Chinese Herbalist 38
  47. 47. For instance, Huang Qi (Radix Astragali Membranacei) and Dang Shen (Radix Codonopsitis Pilosulae) may be added to Xiao Yao San discussed above in order to further supplement the spleen and boost the qi. Che Qian Zi (Semen Plantaginis) might be added to this formula in order to augment the elim- ination of dampness through seeping water or promoting uri- nation. We have seen how Shu Di can be added to further nourish and enrich the blood. Whereas, Huang Qin (Radix Scutellariae Baicalensis) may be added to Dan Zhi Xiao Yao San to clear heat from the lungs and Mai Men Dong (Tuber Ophiopogonis Japonici) might be added to moisten lung dry- ness if prolonged depressive heat floating upward has accu- mulated in the lungs damaging lung fluids. In this case, these two ingredients are added to treat complications of the main disease mechanisms to which this formula’s standard ingredi- ents are targeted. Or, we may add Ju Hua (Flos Chrysanthemi Morifolii) and Bai Zhi (Radix Angelicae Dahuricae) to treat the symptoms of headache located in the eyes and across the brows of the forehead due to depressive heat flaring upward. But we might add Chuan Xiong (Radix Ligustici Wallichii) to treat the symptoms of a temporal headache, especially on the right side. In particular, if we add any of a number of treatment princi- ples beginning with the word zhi or “stop” to the list of stated principles, we must add ingredients specifically to address those acute branch symptoms. As mentioned above, these include vomiting, sweating, diarrhea, bleeding, loss of essence such as from spermatorrhea or abnormal vaginal discharge, and relatively severe pain. All these are seen as very debilitat- ing and harmful to the long-term health of the patient. They need to be stopped as quickly as possible. Therefore, ingredi- ents are added to the formula which are known to have a powerful, pronounced effect on the particular symptom. For instance, excessive bleeding during menstruation may be due to depressive heat entering the blood aspect. There it causes the blood to move frenetically outside its pathways and caus- Writing a Formula That Works for Each Patient Chapter 2 39
  48. 48. es it to overflow beyond measure. In this case, we may use Dan Zhi Xiao Yao San as the guiding formula. But, based on the treatment principles of stopping bleeding, we should also add blood-stopping medicinals, such as Di Yu (Radix Sanguisorbae Officinalis) and Qiang Cao Gen (Radix Rubiae Cordifoliae). Both of these medicinals not only stop bleeding but they do so by specifically cooling the blood according to Chinese medical theory. Organizing our formulas If we begin with a standard formula as a basis or guide, we do not have to worry too much about such traditional organiz- ing principles as ruler, minister, envoy, and assistant. Nevertheless, it is useful to recognize which ingredients play such roles within any formula. This can help in choosing a formula to begin with and in making modifications after a formula is picked. The sovereign ingredient is the main ingre- dient intended to accomplish the main treatment principle. In writing a prescription, this ingredient should be listed first. According to Li Dong-yuan, this ingredient should also be used in the largest amounts, although in contemporary Chinese medicine this is not always the case. The ministerial ingredients are those which aid and extend the functions of the ruling ingredient, while the assistants usually are meant to accomplish allied functions or address specific symptoms. Envoy ingredients are those which carry or target the effects of the rest of the ingredients to a specific viscus, bowel, chan- nel, tissue, or body part. For example, in the famous formula, Bu Zhong Yi Qi Tang (Supplement the Center & Boost the Qi Decoction), Huang Qi (Radix Astragali Membranacei) and Ren Shen (Radix Panacis Ginseng) are the sovereigns. They supplement the qi and for- tify the spleen. Mix-fried Gan Cao (Radix Glycyrrhizae Uralensis) and Bai Zhu (Rhizoma Atractylodis Macrocephalae) are the ministers. They also supplement the qi and fortify the spleen. Dang Gui (Radix Angelicae Sinensis) nourishes the Chapter 2 The Successful Chinese Herbalist 40
  49. 49. blood. Since the blood is the mother of the qi, the addition of Dang Gui helps support the engenderment of qi. This ingredi- ent, therefore, assists the previous four indirectly. And Chen Pi (Pericarpium Citri Reticulatae), Sheng Ma (Rhizoma Cimicifugae), and Chai Hu (Radix Bupleuri) are the envoys. Chen Pi descends turbidity, while Chai Hu and Sheng Ma upbear and lift clear yang. If necessary, one can also add assisting ingredients to address complicating disease mechanisms and their symptoms. For instance, for prolapse of the rectum or uterus, one can add Zhi Shi (Fructus Immaturus Citri Aurantii) to the above. Or, in order to treat urinary frequency and incontinence, one can add Che Qian Zi (Semen Plantaginis) and Ze Xie (Rhizoma Alismatis) if due to spleen dysfunction and Shan Yao (Radix Dioscoreae Oppositae) and Wu Wei Zi (Fructus Schizandrae Chinensis) if due to complicating kidney vacuity. Determining the right dosage Although most Chinese medical textbooks and formula com- pendia give standard or suggested dosages for each formula, Writing a Formula That Works for Each Patient Chapter 2 41 BU ZHONG YI QI TANG Sovereigns Huang Qi Ren Shen Ministers Gan Cao Bai Zhu Assistants Dang Gui Envoys Chen Pi Chai Hu Sheng Ma
  50. 50. the issue of dose is one which requires discussion. If we look at the dosages listed for a standard Chinese formula such as Liu Wei Di Huang Wan discussed above in a modern Chinese medical book such as Him-che Yeung’s Handbook of Chinese Herbs and Formulas, Vol. II and then compare these to the Japanese kanpo yaku dosages of the same formula listed in Hong-yen Hsu’s Commonly Used Chinese Herb Formulas with Illustrations, we will see that the standard professional Chinese dosages are roughly three times more across the board than the kanpo yaku dosages. This same discrepancy is apparent if we look at the dosages of standard formulas as listed in the premodern sources in which they first appeared and their modern Chinese doses compared in Bensky & Barolet’s Chinese Herbal Medicine: Formulas & Strategies. In gen- eral, modern Chinese medical doses are three or more times higher today than in premodern times. This discrepancy between kanpo yaku doses and modern Chinese doses can be explained by the fact that kanpo yaku practitioners prescribe set formulas with little modification. Since the formulas they use, the so-called jing fang or classical prescriptions, come from the Han dynasty and are revered as divine revelations, Japanese practitioners tend to regard them as sacrosanct set pieces. If one formula does not work, anoth- er entire formula is chosen. In addition, kanpo yaku practi- tioners emphasize treating the root or ben as opposed to addressing the branches of a disease. They seem to prescribe relatively simple formulas in small doses to be taken over a protracted period of time with slow, steady improvement on the part of the patient. Modern professional Chinese practitioners, on the other hand, see their patients each week. They do not regard the formulas they use as sacrosanct and inviolable. And they try to achieve relatively speedy relief of all the patient’s branch symptoms at the same time as addressing their disease mecha- nism’s root cause. Thus, modern Chinese medical practition- Chapter 2 The Successful Chinese Herbalist 42
  51. 51. ers tend to prescribe highly modified and fairly complex for- mulas at much higher doses per individual ingredient. The discrepancy between the smaller ancient Chinese doses and larger, modern Chinese doses for the same formulas are more difficult to explain. Is it possible that contemporary patients are sicker than their premodern peers and thus require routinely larger doses? Or is it possible that due to leaching of the soil and overcultivation, Chinese medicinals are not as potent as before. This is not a question we feel we can answer. Typically in the People’s Republic of China today, most ingre- dients in most formulas are dosed at either nine or 10 grams. These numbers are derived from the old, premetric system of weights and measures. In that old system, three qian was a standard dose for ruling and ministerial ingredients, two qian for assistant ingredients, and one qian for envoy ingredients. One qian is slightly more than three grams. Therefore, some practitioners routinely prescribe nine grams for the main ingredients in their formulas and others prescribe 10 grams. Those that stick to nine grams do so, in part, because nine is an odd or yang number just as three qian is. Those Chinese practitioners that prefer to use 10 grams tend to also be those most influenced by modern Western medicine. Personally, I prescribe mostly on the basis of multiples of 3 – 1.5, 3, 4.5, 6, 9, 12, 15, 18, 21, etc. However, this should be recognized for what it is, a somewhat arbitrary convention based on theory and numerology, not on chemistry. In a modern Chinese medicinal formula, when more than 9- 10 grams of an ingredient are prescribed, there are usually either of two factors at work. First, if a branch symptom is severe, a larger than normal amount of an ingredient may be used. Thus, if qi vacuity is severe, one may use 12, 30, or even 60 grams of Huang Qi (Radix Astragali Membranacei). In this case, Huang Qi may or may not be the ruling ingredient. Secondly, some ingredients are simply known to be effective Writing a Formula That Works for Each Patient Chapter 2 43
  52. 52. at higher than the usual doses. For instance, Pu Gong Ying (Herba Taraxaci Mongolici Cum Radice) and Bai Jiang Cao (Herba Patriniae Heterophyllae) are routinely prescribed at 21- 30 or more grams per packet because those are the doses at which they become effective. Typically, these ingredients are not the ruling ingredients in the formulas in which they appear. Likewise, when less than 9-10 grams of a single ingredient are prescribed in a modern Chinese medicinal formula, this is usually due to similar reasons. Either the ingredient is merely adjunctive, functioning as an envoy or assistant, or it is so strong-acting and even potentially toxic that it has been determined that only a certain smaller dosage is necessary and advisable. In addition, standard dosages of certain ingre- dients may be reduced if it is understood that, in a given patient, based on their pattern discrimination, that ingredient is likely to cause unwanted side effects or iatrogenesis. Therefore, although there are standard dosages used in modern Chinese medicine for most ingredients in most formulas, the exact amounts of any ingredient in any formula are a matter of judgement on the part of the prescribing practitioner. That is why, in many Chinese medical books, dosages are not given for any ingredients in any listed formulas. In deciding on the dosage of each and every ingredient in a formula, the practitio- ner is expected to know and understand why the ingredi- ent is in the formula and, further, how much of that ingredient in the formula our individual patient needs and can tolerate. In other words, we must have a firm grasp of the materia medica with all the medicinals’ fla- vors, temperatures, channel Chapter 2 The Successful Chinese Herbalist 44 Although there are standard dosages used in modern Chinese medicine for most ingredients in most formu- las, the exact amounts of any ingredient in any for- mula are a matter of judge- ment on the part of the pre- scribing practitioner.
  53. 53. gatherings, functions, indications, combinations, contraindica- tions, and usual dosage ranges. We need to become so acquaint- ed and conversant with the Chinese medicinals that we can immediately know why any ingredient is in any formula. Then it is relatively easy to decide how much of that ingredient a spe- cific patient should be given. Some Western practitioners feel that the contemporary Chinese norm of 9-10 grams per ingredient per packet is arbitrary. Some feel it is too much or unnecessary. However, in reviewing the modern Chinese medical journal literature, it seems to me that the dosages of individual ingredients prescribed in China are tending to be even higher than 9-10 grams per ingredient. It is not uncommon today to see the majority of ingredients in a formula listed at 12-15 grams per ingredient per day. In my experience, however, most Western patients simply cannot afford the cost of such large bao or packets. Typically, I use nine grams per ingredient as my standard dose per packet which I have the patient spread out over a two day period. For the majority of my patients this compromise allows them to get results, if perhaps slower than otherwise, at a price per day they can afford. I frequently would like to give higher doses but only do so in extraordinary situations or for serious branch symptoms and short durations. At some point, I do think we as practitioners should do comparative studies measuring the effectiveness of different dosages on a single patient population. Until that time, decid- ing on exact dosages per ingredient must depend on personal knowledge and experience and on an assessment of what the consumer can afford. Other factors that can and should be taken into account when deciding upon dosages are the season, weather, and pre- vailing geographic environment and the patient’s age, sex, size, and constitution. Li Dong-yuan, in his Pi Wei Lun (Treatise on the Spleen & Stomach), gives much interesting Writing a Formula That Works for Each Patient Chapter 2 45
  54. 54. advice on the modification and adjustment of dosages of for- mulas based on the season and weather. For instance, some herbal practitioners suggest that the dosages of Si Wu Tang (Four Materials Decoction) be altered for each of the four sea- sons. This standard formula consists of: Dang Gui (Radix Angelicae Sinensis) Bai Shao (Radix Albus Paeoniae Lactiflorae) Shu Di (cooked Radix Rehmanniae Glutinosae) Chuan Xiong (Radix Ligustici Wallichii) In the spring, yang qi rises upward and it is important that the liver’s control of coursing and discharge be freely and eas- ily flowing. Therefore, one might consider doubling the dosage of Chuan Xiong during the spring. During the summer, the weather is hot and one may sweat profusely. Patients requiring this formula have a tendency to be blood and yin vacuous and insufficient. Therefore, one might consider dou- bling the amount of Bai Shao in the summer. This medicinal is cold and also astringing, thus tempering the heat of the season and controlling perspiration. Fall is the season of dry- ness, and blood and body fluids share a common source. Therefore, one might consider doubling the amount of Dang Gui in this formula in the fall. And finally, the winter is the season of the kidneys and a time of storing essence. Shu Di not only nourishes the blood but supplements the kidneys and fulfills essence. Thus one might consider doubling Shu Di in the winter. The rationale behind these seasonal modi- fications is based on understanding the nature and uses of each ingredient and the tendencies and requirements of each season when seen from the perspective of the typical patient needing Si Wu Tang. Obviously, infants and children should be given reduced dosages. This may be calculated by body weight. We can, in general, prescribe the same percentages of adult doses of each ingredient as the proportion of the child’s weight to an Chapter 2 The Successful Chinese Herbalist 46
  55. 55. adult’s. We can also administer Chinese herbal decoctions to infants and small children by the dropper. Most American children will not drink even a quarter cup of an herbal decoc- tion if given in a cup. However, they will drink the same decoction if squirted into their mouth via a dropper. In this case, we can give smaller but more frequent doses through the day rather than 2-3 larger doses. Decocting & administering bulk-dispensed Chinese medicinals Chinese society was, until the last 50 years, by and large, a sedentary, agrarian society. Patients of Chinese doctors lived nearby. They cooked their meals three times per day. Therefore, they came to depend upon decoctions or tang (lit- erally soups) as their major method of medicinal administra- tion. This is in contradistinction to nomadic Tibetans and Mongols who primarily came to rely on pills and powders. There are a number of different methods of making a Chinese decoction. In fact, every teacher with whom I have studied Chinese medicine has had their own, slightly different method. The method I use with my patients is to simmer the herbs in six cups of water till they are reduced to approxi- mately three cups. If there are shells or minerals in the decoc- tion, these should be decocted for 30-45 minutes in advance before the other ingredients are added. If there are various aromatic substances in the formula, these may have to be added at the end of the cooking for the last 5-7 minutes. These include Sheng Jiang (uncooked Rhizoma Zingiberis Officinalis), Gou Teng (Ramulus Uncariae Cum Uncis), Chuan Xiong (Radix Ligustici Wallichii), Mu Xiang (Radix Aukandiae Lappae), Yan Hu Suo (Rhizoma Corydalis Yanhusuo), and Sha Ren (Fructus Amomi) to name a few of the most common such ingredients. Some flowers, such as Hong Hua (Flos Carthami Tinctorii) and Ju Hua (Flos Chrysanthemi Morifolii) should only be steeped at the end. The various gelatins, such as E Jiao (Gelatinum Corii Asini) and Lu Jiao Jiao (Gelatinum Cornu Cervi), should be broken up first and then dissolved in the hot Writing a Formula That Works for Each Patient Chapter 2 47
  56. 56. liquid after the liquid has been strained and the dregs removed. Certain resinous powders, on the other hand, such as Hu Po (Succinum), should be chased down when drinking the decoc- tion. In addition, some very small ingredients need to be placed in cotton muslin bags during decoction so that they do not get caught in or irritate the throat when drinking the decoction. This includes Pu Huang (Pollen Typhae), for instance. Using the method above, one makes up six half-cup doses every two days and stores these for use in a clean, lidded, glass jar. If the weather is not too hot, this can be stored with- out refrigeration for the 36-48 hours necessary till it is used up. If the decoction is meant to clear heat, it may be drunk at room temperature. If the decoction is meant to supplement yang or warm the interior, it is best if each dose is reheated. Some American practitioners allow their patients to make up even 4-5 days’ decoction at a time. However, my experience is that the flavor of stored decoctions changes after 36-48 hours. This change in flavor suggests to me that the decoction itself has undergone a chemical change and is no longer the same physical substance. Therefore, I have no assurance that it will have the same, intended effect. Because of this, I recommend my patients to only make up two days’ supply of decocted herbs per time. If I want my patients to get a higher, more potent dosage of decocted herbs, another method I sometimes use is to cook one bao or packet as above but with only three cups of water. This results in 11/2 C of decoction, or a one day’s dose at 1/2 C, three times per day. However, instead of discarding the dregs, I tell the patient to reserve them in the refrigerator. The second day, the patient makes up a new bag of herbs just like the day before. Again they reserve the dregs. On the third day, they take the dregs, combine them, and recook them the same way to get a third day’s dose from the ingredients of the two combined packets. Chapter 2 The Successful Chinese Herbalist 48
  57. 57. A somewhat similar method of stretching a single bao or packet of medicinals is to decoct it twice and then pour together the resulting two decoctions. However, in the People’s Republic of China, most patients use only one bao per day. The method I was taught in Shanghai was to place the medicinals in a teapot and cover the medicinals with cold water one inch or so above the top of the medicinals. These medicinals are then allowed to soak for one hour. Then they are decocted for 45 minutes. After decoction, they are decant- Writing a Formula That Works for Each Patient Chapter 2 49 INGREDIENT COOKING METHOD SAMPLE INGREDIENTS SHELLS & MINERALS GINSENGS MOST MEDICINALS AROMATIC MEDICINALS FLOWERS RESINOUS POWDERS FINE POWDERS Simmer for 30-45 min- utes prior to adding main ingredients Mu Li and Long Gu Simmer whole roots separately for 30-45 minutes. Then eat the ginseng root. Add liq- uid to main ingredient liquid. Ren Shen Simmer in 6 cups down to 3 cups for 30-45 minutes Add during the last 5-7 minutes of cooking Sheng Jiang, Gou Teng,Chuan Xiong, Mu Xiang, Yan Hu Suo, Sha Ren Steep after the heat is turned off for 5 minutes Hong Hua and Ju Hua GELATINS Dissolve in the hot liquid Put in mouth and chase down with decoction Place in a muslin bag when cooking so that powders are not difficult to drink E Jiao and Lu Jiao Jiao Hu Po Pu Huang

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